Dr. Robert Hecht is Principal and Managing Director at Results for Development Institute, a Washington, D.C.-based nonprofit that works on health, development, and education issues.

Dr. Robert Hecht is Principal and Managing Director at Results for Development Institute, a Washington, D.C.-based nonprofit that works on health, development, and education issues. He is editor of the just-published “Costs and Choices: Financing the Long-Term Fight Against AIDS,” an aids2031 project.

Hecht spoke with John Donnelly about the recent UNAIDS report that showed HIV prevalence declined by at least 25 percent in 22 countries in sub Saharan Africa over the last decade.

Q: What do these findings tell you?

A: It tells me that the rate of new infections is starting to come down in a number of countries from frightening high levels in the past. It means that some of the things we are doing in prevention are starting to have an impact. At the same time, looking at the other side of the coin, looking at infections that continue to accrue, it suggests a lot more needs to be done to go further in order to have significant HIV reduction. What it means is, until we make a further dent on the prevention side and stopping people from becoming infected, we are setting up a situation in the future where we are adding to the numbers of the people who need to be cared for and who need to be put on treatment. Those numbers of people continue to grow.

Q: What’s working in prevention that would account for the 25 percent drop?

A: In some countries where infection rates have been astronomically high, especially in southern and eastern Africa, given the saturation of infection with HIV, there is a certain amount of natural decline even when prevention isn’t working at all. We have seen some falls in new infections in countries that have not done a good job in prevention. We’re also seeing behavior change in young people, where they are having sex at a later age, having fewer partners and using condoms more regularly. That has led to falling rates among young men and women, but this is not the case across all age groups. In addition, there have been some important expansions in some programs, such as mother to child transmission.

Q: You’re saying that the 25 percent decline in these countries shouldn’t lessen the sense of urgency in efforts to prevent new infections.

A: In the high-prevalence countries of eastern and southern Africa, we are still seeing every year between 1 and 2 percent of the total population newly infected each year. If the rate of new infection is down 25 percent, in a country that had 2 percent of adults infected every year now would have 1.5 percent infected. That’s still hundreds of thousands of people infected. Just to give one example — in South Africa, 1.5 percent of adults are infected every year. That’s nearly 500,000 people. With a 25 percent reduction, that’s 375,000 people – and that’s way above the numbers of people South Africa has been adding to the treatment rolls every year. So South Africa and other countries are scrambling now not to keep on falling further behind. Sustaining an additional 375,000 people on treatment every year is going to be extremely burdensome.

Q: What should countries be doing now in preventing new infections?

A: The next frontier — where should they focus, what is going to get them the most bang for the buck – involves three things. One is to do some things we know work but haven’t been done in a big way – such as male circumcision and nationwide screening of pregnant women to make sure they don’t pass on the virus to babies if they are infected. Number two is even in countries in southern Africa, with its high HIV prevalence, we are learning more and more from detailed studies that a significant fraction of new infections are still happening in men having sex with men, commercial sex workers, and injecting drug users, so have these countries take a fresh look at targeting high-risk populations. And the third thing – the really tough nut to crack – is a sustained effort with political leaders and religious leaders and others to reduce the number of multiple sex partners, being faithful to one partner, and to increase use of condoms.

Q: What about the impact of treatment to prevent the spread of HIV?

A: We are getting some benefit already from treatment, and it’s one of the factors that is leading to the 25 percent reduction. As more and more people get put on treatment, it will have a larger prevention effect. But to have a huge prevention effect, a country would have to be very committed to greatly expanding a testing-and-treatment program, and that would be extremely expensive. There is some logic to a huge expansion of treatment, but the countries would have to mobilize and donors would have to put up funding on a scale we have never seen before. There is talk now about trying it out in a few districts of Kwa-Zulu Natal in South Africa to see if it works. I’m all for that so we can see what the results would be.

You say that male circumcision works. If so, how to you account for the Wawer study that found women had a higher HIV infection rate when having sex with circumcised men? (The Lancet, Volume 374, Issue 9685, Pages 229 – 237, 18 July 2009)

The circumcision campaign focuses on male circumcision and the transmission vector from women to men. Evidence shows that male circumcision increases the incidence of HIV with the transmission vector from men to women.